Pressure care
Mattress
35. Miss O says the Trust failed to provide Mr O with a mattress that was appropriate for his needs. Miss O detailed in her complaint correspondence how a physiotherapist had commented on the mattress, saying they could feel the metal when they knelt on it. Miss O also said a nurse commented on the mattress to the family.
36. We can understand Miss O’s concern about this, particularly given her account of comments made by members of staff.
37. The NICE pressure ulcer guidance covers the risk assessment, prevention, and treatment in patients at risk of, or who have, a pressure ulcer. It aims to reduce the number of pressure ulcers in people admitted to hospital.
38. The NICE pressure ulcer guidance recommends the use of a high-specification foam mattress for adults with a pressure ulcer. If this is not sufficient to redistribute pressure, then the use of a dynamic support surface should be considered. The guidance says standard-specification foam mattresses should not be used for adults with a pressure ulcer.
39. Our TVN adviser explained a dynamic support mattress is a mattress that gives pressure relief using air-filled cells. These alternate with air to ensure the deflated mattress cells are not in contact with that area on the body, therefore giving pressure relief.
40. The Trust transferred Mr O to an Autologic mattress on 26 November 2017, while he was on MAU. An Autologic mattress provides dynamic support and is used for pressure area management of very high-risk patients. Our TVN adviser said this was an appropriate mattress for Mr O, based on his category of risk.
41. The Trust transferred Mr O to a Smart Care mattress on 13 December 2017. This mattress is a hybrid mattress. It can work as a high specification foam mattress or, when an electronic pump is added, can give more effective pressure relief. It is intended for patients at very high risk of developing pressure ulcers and for patients with pressure damage.
42. This transfer was due to the Trust changing the supply of mattresses across the hospital. Our TVN adviser said there was no clinical need to transfer Mr O from the Autologic to the Smart Care mattress, but this new mattress was also appropriate for Mr O’s needs.
43. We considered Miss O's account of comments made by members of staff, and the evidence available in the records. We found the Trust nursed Mr O on mattresses which were in line with the NICE pressure ulcer guidance recommendations. We have not upheld this part of the complaint.
Assessment, prevention and treatment
44. Miss O says the Trust failed to hoist Mr O into bed in a timely manner to provide pressure relief. Miss O has detailed, in her complaint correspondence, how Mr O was not hoisted out of bed daily, despite the physiotherapist recommending this and it being noted above Mr O’s bed.
45. Miss O says when Mr O was hoisted out of bed he was left for several hours, not two hours, as had been advised. She also says the Trust failed to assess the sacral sore that developed, or to treat it.
46. The NICE pressure ulcer guidance says a pressure ulcer risk assessment should be completed on admission to hospital.
47. The Trust uses the Waterlow risk assessment, which calculates the risk of an individual developing pressure ulcers, using a simple points-based system. The Waterlow risk assessment should be repeated at least weekly, or when the patient’s condition changes.
48. We can see the Trust used the Waterlow risk assessment for Mr O when he was admitted to hospital. It did not fully complete the risk assessment, because it did not include his nutritional status. Despite this, the Trust assessed Mr O as being at very high risk of developing pressure ulcers.
49. We can also see the Trust undertook reassessments at regular, but not weekly, intervals. There is evidence that the regular assessments ranged from taking place one day early, to seven days late.
50. There were also times when the Trust has noted Mr O’s condition changed, but it did not undertake a reassessment. For example, on 27 November, the Trust noted Mr O had a moisture lesion, but it did not undertake a reassessment. When the Trust did reassess Mr O’s risk for developing pressure ulcers, he remained consistently at a high, or very high, risk.
51. We found the Trust failed to assess Mr O’s risk of developing pressure ulcers in line with the NICE pressure ulcer guidance and the Waterlow risk assessment tool. Given Mr O was at high, or very high risk, we have gone on to consider what action the Trust should have taken.
52. The NICE pressure ulcer guidance recommends a documented individualised care plan for patients who have been assessed as being at high risk of developing a pressure ulcer. This should take into account:
· the outcome of the risk and skin assessment · the need for additional pressure relief at specific at-risk sites · the patient’s mobility and ability to reposition themselves · any comorbidities · the patient’s preference.
53. The NICE pressure ulcer guidance also recommends that adults who have been assessed as being at high risk of developing a pressure ulcer, be encouraged to change their position frequently, and at least every four hours. If they are unable to reposition themselves, they should be offered help using appropriate equipment, if needed. The guidance says the frequency of repositioning required should be documented.
54. The Trust uses ‘SSKIN’ bundle, which is a five-step approach to promoting pressure ulcer prevention. This includes skin assessment, the surface the patient is nursed on, movement of the patient, consideration of incontinence and moisture, and nutrition.
55. There is some evidence of Mr O having his position changed, but there are also times (for example, between 6 and 8 December) when the Trust has not recorded Mr O’s position. The Trust has also recorded some difficulties at times because Mr O was unable to cooperate.
56. There is limited information about where Mr O was cared for, for example whether he was in bed (with the mattress giving pressure relief) or in a chair. When he was in a chair, it was not clear whether equipment, such as a cushion, was used to give pressure relief.
57. Miss O has provided us with photographs of her father sat in a chair. She has explained how Mr O was sat out when visited by family in the morning, and he would still be in the same position when visited later in the day. It appears from one of the pictures that a cushion may have been in place.
58. According to the documentation, it appears the Trust nursed Mr O in a chair between 2pm on 8 December until 9am on 9 December. We have seen no evidence about whether the Trust used any pressure prevention equipment, such as a cushion, to relieve pressure while Mr O was sat in the chair either during this time, or at any other time.
59. We have found the Trust failed to put in place an individualised care plan for Mr O. We can see some evidence the Trust provided elements of the care that should have been included in the care plan, such as repositioning Mr O, and using pressure prevention equipment. But according to the records, the Trust failed to consistently take steps to prevent a pressure sore developing.
60. Moisture lesions occur because of prolonged exposure to moisture such as urine, faeces, perspiration, or a weeping wound. They vary in size, colour, and shape. They appear as patches of sore skin, which sometimes blister, and erosions form. The skin feels cold, wet, or clammy.
61. Pressure ulcers are primarily caused by prolonged pressure on the skin. The European Pressure Ulcer Advisory Panel guidance says pressure ulcers should be categorised or graded, demonstrating the depth and severity of pressure damage.
62. The NHS website says a category one pressure ulcer may involve part of the skin becoming discoloured, or a patch of skin that feels warm, spongy, or hard. A category two pressure ulcer is an open wound or blister. A category three pressure ulcer is a deep wound that reaches the deeper layers of the skin. If the depth of the wound reaches the muscle or the bone, it is a category four pressure ulcer.
63. Our TVN adviser said wound assessment was important to be able to provide a baseline for comparison as the wound progresses.
64. The Trust recorded the location of the skin damage inconsistently. At times the Trust notes the area of skin damage as being between the natal cleft, while at other times the Trust noted it as being the sacrum. Our TVN adviser explained the sacral area is positioned at the top of the natal cleft, over a bony prominence.
65. The Trust’s assessment of the severity of the skin damage was lacking in detail. The assessment appears to change between a moisture lesion and grade one to two pressure damage. The only recorded size of the wound was on 17 January, when the Trust described grade two pressure damage measuring 1cm by 1cm.
66. We have found the Trust failed to consistently assess and document the integrity of Mr O’s skin. When the Trust did note damage to the skin, it took limited action.
67. When the Trust first noted a moisture lesion, there was no evaluation of the care provided and no care plan was put in place. When it noted a ‘? grade 1-2/? moisture lesion’, it applied a barrier cream, but took no further action. Days later, it again noted a moisture lesion/grade two skin damage, but it did not evaluate the wound or escalate care, and there was no care plan in place.
68. The NMC guidance says nurses must work cooperatively in referring matters to colleagues when appropriate and working with colleagues to preserve the safety of those receiving care.
69. Our TVN adviser said at first the nursing staff could manage Mr O at ward level and did not require specialist input. We are satisfied that initially the nurses acted in line with the NMC guidance. However, when Mr O’s skin integrity deteriorated, the nursing staff should have considered referring Mr O to a tissue viability nurse.
70. We have found the Trust failed to consider referring Mr O to the tissue viability nursing team in a timely manner.
71. The NMC guidance also says nurses should keep clear and accurate records that are relevant to their practice. It says records must identify any risks or problems that have arisen, and the steps taken to deal with them, so that colleagues who use the records have all the information they need.
72. Despite using the ‘SSKIN’ bundle documentation, the Trust’s record keeping about the care it provided to Mr O is poor. The records that do exist are conflicting and inconsistent. The Trust has regularly noted ‘pressure relief maintained’ in the clinical records, without giving any detail of what that entailed.
73. Considering the information we have set out throughout the paragraphs above, we have found the Trust failed to keep records in line with both the NMC guidance and the NICE pressure ulcer guidance.
74. We have seen failings in record keeping relating to the risk assessment, the care plan, the assessment of Mr O’s skin, and the actions taken to prevent a pressure sore developing. The records it has kept are lacking in detail, incomplete, and inconsistent.
75. In summary, we have found the Trust failed to assess Mr O’s risk of developing a pressure ulcer or to put in place an individualised care plan that was in line with the NICE guidance. The Trust failed to consistently assess Mr O’s skin, provide pressure relief, and to reposition Mr O. We think these actions were not in line with the NICE guidance.
76. We have found when the Trust did implement elements of a care plan, the documentation of the actions taken was poor. We have also found the Trust failed to refer Mr O to the tissue viability nurse in a timely manner. We think these actions were not in line with the NMC guidance.
77. We have considered the impact of these failings on Mr O and his family.
78. As set out above, we think the evidence shows Mr O’s skin was intact on his admission to hospital. Because the Trust’s assessment of Mr O’s skin was poor and inconsistent, based on the records, we cannot say what type of wound was present.
79. This uncertainty in itself is an injustice to Miss O, as we are unable to fully address her concerns.
80. What we can say is that it appears from the hospice records that Mr O’s skin was no longer intact on admission. The hospice recorded a grade three to four pressure ulcer. The Trust has suggested the hospice may have used a different grading process, or that the training may have been different for the hospice staff.
81. However, the hospice records are consistent that this was a grade three to four pressure sore. The medical certificate of cause of death also recorded it as a grade four sacral pressure sore.
82. Irrespective of what grade the skin damage was, we think the likely impact of this was fatal for Mr O. We have explained why below.
83. On 15 January, the Trust had noted Mr O’s c-reactive protein (CRP – measures inflammation and can be an indication of infection) was rising. It arranged blood tests and a blood culture.
84. On 17 January, the Trust noted the blood cultures had grown staphylococcus aureus (a type of bacteria frequently found on the skin). The Trust started IV antibiotics for staphylococcus aureus bacteraemia (the presence of bacteria in the blood stream).
85. Given staphylococcus aureus is commonly found on the skin, and given it is likely Mr O’s skin was no longer intact due to the Trust’s failings, we think it is more likely than not that the staphylococcus aureus entered the blood stream as a result of the break in the skin. On 18 January, the Trust noted the likely source was the ‘pressure ulcer on buttock’.
86. We can see the Trust provided Mr O with treatment for sepsis. He was treated with a long course of IV antibiotics to treat the infection. This was in line with NICE guidance - Sepsis: recognition, diagnosis and early management (NG51), 2016.
87. Despite this treatment, Mr O did not have the reserves to recover from the overwhelming infection caused by the pressure ulcer.
88. We acknowledge Mr O was a frail man, who was in the end stages of Alzheimer’s. However, on the balance of probabilities, we think Mr O’s death occurred as a result of the Trust’s actions. We think he would not have died at that point had the failures, set out above, not occurred.
89. If the Trust had assessed and provided care in line with the relevant NICE and NMC guidance outlined above, we think it is more likely than not that Mr O would not have sustained skin damage. In turn, Mr O would not have gone on to develop bacteraemia or sepsis.
90. We note the coroner concluded Mr O died due to sepsis, which occurred due to staphylococcus aureus bacteraemia. The coroner noted the likely source was the sacral pressure ulcer, which was recorded as a grade three to four sacral pressure sore.
91. Miss O has told us of her distress at her father’s death. She has told us how she has found it distressing her father died in pain, and how she thinks he was scared. She has told us how she continues to experience flashbacks and nightmares. She says she did not know what was happening at the time, so was unable to protect her father, or to prevent him suffering.
92. It is clear this had a devastating and lasting impact on Miss O. We do not think the Trust has recognised this, or how the uncertainty caused by the poor records have made matters worse. We have upheld this part of the complaint. We have made recommendations to address the injustice Miss O has experienced.
Communication with the family
93. Miss O also complains the Trust did not inform the family about the pressure sore in a timely manner. Miss O has detailed in her complaint correspondence how the family found out about the pressure sore on 19 January. This was because the Trust told the family the infection Mr O had was likely due to the pressure sore.
94. Miss O says the Trust never discussed the severity of the pressure sore. She says it was not until Mr O was admitted to the hospice that they were informed of the category of the pressure sore, and that as a result, the coroner would need to be informed.
95. The NPSA guidance says organisations should communicate with patients, their families, and their carers, as a vital part of the process of dealing with patient safety incidents. The NMC guidance says nurses should share with people, their families, and their carers, the information they want or need to know about their health, care and treatment.
96. The Trust has documented that Mr O’s daughters were his main carers and that Mr O would like them to be involved in his care. Any safety issues should therefore have been discussed with Mr O’s daughters, given his cognitive decline and the wishes he had expressed.
97. Mr O had acquired the pressure sore while in hospital. Our nursing adviser said this was a patient safety incident. In line with the NPSA guidance, this should have been discussed with Mr O’s daughters. Our nursing adviser suggested Trust staff should have discussed this as early as 4 January, when it appears they first noted the grade two pressure sore.
98. We have been unable to find any discussion with Mr O’s family about the damage to Mr O’s skin. We understand this took place when the family were informed the pressure ulcer was the likely source of the infection. We have taken this from the complaint correspondence, rather than finding this recorded in the medical records.
99. We have found the Trust failed to communicate with Mr O’s family in line with the NPSA guidance and the NMC guidance. The Trust should have communicated with the family earlier about the presence of the damage to Mr O’s skin.
100. We can understand it was distressing for Miss O to suddenly discover Mr O had a pressure ulcer and that this had caused Mr O additional complications to his health. We have upheld this part of the complaint. We have made recommendations to address the injustice Miss O has experienced.
End of life care
101. Miss O complains that one of the reasons Mr O was started on end-of-life care was because his catheter was not draining, but this was later resolved. She is concerned that by this point, the Trust had stopped fluids and the daily medication Mr O needed to manage his other health conditions.
102. The NICE care of dying adults guidance says it can often be difficult to be certain a person is dying, and the NICE guidance should be used alongside clinical judgement.
103. The guidance says there should be an assessment for changes in signs and symptoms in the person. These changes may include the following:
· signs such as agitation, Cheyne–Stokes breathing, deterioration in level of consciousness, mottled skin, noisy respiratory secretions, and progressive weight loss · symptoms such as increasing fatigue and loss of appetite · functional observations such as changes in communication, deteriorating mobility or performance status, or social withdrawal.
104. Our geriatrician adviser said Mr O was experiencing some of these clinical changes. He had a decreased level of consciousness, a reduced appetite, changes in communication, decreased mobility and performance status, and mottled skin.
105. On 21 January, Mr O’s Glasgow Coma Scale (GCS, a measure of consciousness) was 9/15. This showed a decreased level of consciousness as the GCS ranges from 3 (completely unresponsive) to 15 (responsive).
106. Mr O’s C-reactive protein increased despite high doses of intravenous antibiotics given for several days, and he had a worsening renal function.
107. Mr O had a temperature, and widespread crackles were heard throughout his chest. He had an increased oxygen requirement which went from two litres of oxygen to four litres, within a few hours.
108. The Trust gave Mr O an IV fluid challenge. This is where the patient receives a small amount of fluid over a short period of time, to help assess the cause of a patient’s low blood pressure. Mr O’s blood pressure was low, but he initially responded to the IV fluid challenge. His capillary refill time was about ten seconds (normal is less than two to three seconds). The Trust continued to provide slow IV fluids, but Mr O’s blood pressure became low again.
109. It was clear that Mr O had fluid overload (fluid on the lungs) as a result of his illness, and his blood pressure was still low. The Trust could not give any more fluids to increase his blood pressure because this would cause the fluid accumulated in his lungs to increase and cause further distress to him.
110. Our geriatrician adviser said at this point it was clear that Mr O’s condition would not improve no matter what intervention was put in place.
111. We acknowledge Miss O’s concerns about Mr O’s catheter, and the influence this may have had on the decision. We can also see the Trust took into account a range of clinical factors when reaching its decision.
112. We have found no failing in the Trust’s decision to start end-of-life care for Mr O. It appears the Trust assessed Mr O’s condition in line with the NICE care of dying adults guidance. We have not upheld this part of the complaint.
Bladder and bowel care
113. Miss O complains about bladder and bowel care provided by the Trust. She says Mr O went a number of days without a bowel movement and no medication was prescribed to address this. She has also told us how she raised this with the nurses on numerous occasions.
114. The GMC guidance says doctors must provide a good standard of practice and care. If they assess, diagnose, or treat patients, they must adequately assess the patient’s conditions and take account of their history, examining the patient when necessary. They must promptly provide or arrange suitable advice, investigations, or treatment where necessary.
115. The Trust uses the Bristol Stool Chart (BSC) to monitor the bowel habits of patients. The BSC is an evidence-based chart which the NHS widely uses. The chart grades the stool between types one to seven (where one is separate hard lumps, indicating constipation, and seven is liquid consistency with no solid pieces, indicating diarrhoea) and each stool should be recorded.
116. The Trust completed a BSC for Mr O between 10 and 26 December, and between 8 and 21 January. When used, the Trust recorded Mr O’s stool as being between type four (soft) and type six (mushy).
117. There is no reason given in the notes about why the Trust did not complete a BSC for Mr O between 26 December and 8 January. On 28 December, the Trust noted that Mr O had not had a bowel movement. Again, on 6 January, the Trust noted Mr O had not had a bowel movement.
118. It is difficult for us to say whether the lack of records between 26 December and 8 January was because the Trust failed to record this, or because Mr O had not opened his bowels during this time.
119. Our geriatrician adviser said that, in line with the GMC guidance, if Mr O had not opened his bowels during this time, the Trust should have prescribed laxatives, or suppositories.
120. We can see on 2 January, the Trust prescribed laxatives but did not administer these. This suggests Mr O had not opened his bowels between 26 December and 2 January, otherwise there would have been no reason for the Trust to have prescribed the laxatives.
121. We can also see on 8 January the Trust prescribed and administered a suppository. Again, this would suggest Mr O had not opened his bowels for a period of time, otherwise the Trust would not have needed to prescribe this.
122. On the balance of probabilities, we think it is likely that between 26 December and 8 January, Mr O did not open his bowels regularly. It is likely this caused Mr O discomfort during this time.
123. We recognise Mr O had communication problems because of his dementia. He would not therefore have been able to communicate feelings of pain and discomfort verbally to staff. This made it more important for the Trust to accurately monitor Mr O.
124. Mr O could have had faecal impaction, but there is no evidence this occurred. If it had, the records would show Mr O had experienced a watery overflow, and there is no evidence this occurred. Instead, when Mr O’s bowels did open on 8 January, he had medium sized stools.
125. We have found the Trust failed to act in line with the GMC guidance. It is likely that, due to a lack of records, the Trust did not adequately assess Mr O’s condition or provide him with treatment. This likely led to some discomfort for Mr O and we understand this was distressing for Miss O.
126. We have upheld this part of the complaint. We have made recommendations to address the injustice Miss O has experienced.
127. Miss O also says the Trust catheterised Mr O without consent. She says the Trust completed forms to say Mr O had provided consent, but Mr O did not have the capacity to do this.
128. The RCN guidance says incontinence alone is not a reason for catheterisation unless the patient has extensive skin damage from moisture, and the patient’s incontinence can only be managed by catheterisation. Other reasons for catheterisation include the inability to empty the bladder (urinary retention), monitoring renal function, and other voiding difficulties.
129. The guidance also says ‘valid consent or authorisation’ needs to be obtained before carrying out catheterisation, and consent can only be given by the patient. To enable a patient to give consent, they must have capacity to understand and retain the information and be able to weigh the risks against the benefits.
130. The Royal Marsden guidance says patients with an acute kidney injury (AKI) should have their fluid output monitored accurately.
131. We can see from the records Mr O was catheterised on 10 December. The records show staff explained the reason for catheterisation to Mr O and that he understood. The documented reason was because Mr O had an AKI. The Trust noted this was a stage two AKI.
132. We have found the Trust’s reason for inserting the catheter was in line with the RCN guidance and Royal Marsden guidance. Our nursing adviser said the decision was in Mr O’s best interests, as it was crucial for monitoring urine output, in the context of the AKI.
133. However, we have concerns about the Trust’s documentation about this, and its communication with Mr O’s family.
134. As set out above, we think it is likely the decision to insert the catheter was in Mr O’s best interests. The Mental Capacity Act says that if a person has been assessed as lacking capacity then any action taken or any decision made for, or on behalf, of that person may be made in the person’s best interests.
135. The person who has to make the decision will normally be the person responsible for the day-to-day care. Our nursing adviser said in this instance, the nurse caring for Mr O that day would have been the decision maker.
136. The Mental Capacity Act says people involved in caring for the person lacking capacity have to be consulted concerning a person’s best interests. Our nursing adviser explained this does not mean consent is needed, but that relevant people, in this case Mr O’s family, should be informed.
137. The NMC guidance says nurses must keep clear and accurate records. In line with this, the nurse should not have documented that Mr O had consented. The nurse should have documented the decision to catheterise was made in Mr O’s best interests.
138. We have found the Trust failed to act in line with the NMC guidance when it recorded Mr O had provided consent, as Mr O did not have capacity to consent. We have also found the Trust’s communication was not in line with the Mental Capacity Act, the NMC guidance (which says nurses should communicate clearly), or the GMC guidance (which says doctors should communicate effectively).
139. We can understand why it was distressing for Miss O to unexpectedly find Mr O with a catheter. This was understandably made worse by the Trust’s poor communication about why the catheter had been used and being told Mr O had provided consent. We have upheld this part of the complaint. We have made recommendations to address the injustice Miss O has experienced.
Medication and swallowing
140. Miss O complains the Trust failed to refer Mr O to SALT, despite concerns about a possible lack of swallowing and potential aspiration. She says she had repeatedly asked for SALT to be involved. Miss O also complains about the Trust’s administration of prescribed medication.
141. Dysphagia is an impairment of swallowing. Patients with dysphagia may experience difficulties with swallowing, reporting food sticking, require additional time to eat a meal, or avoid certain food.
142. The GMC guidance says doctors should refer a patient to another practitioner when this serves the patient’s needs. Similarly, the NMC guidance says nurses must work cooperatively in referring matters to colleagues when appropriate and working with colleagues to preserve the safety of those receiving care.
143. The Royal Marsden guidance says it is important to correctly ascertain the presence of dysphagia, as these patients may be at risk of aspiration and subsequent chest infections. It says for patients at risk of dysphagia, a referral to SALT for a full assessment is required.
144. Our nursing adviser reviewed the food intake charts. These show a varied intake. On 24 December, Mr O was noted to be holding some food in his mouth. On 26 December and 10 January, he was noted to have eaten all of his food. Our nursing adviser said the food he was given would have been virtually impossible for someone with swallowing difficulties to eat.
145. However, on 28 December the Trust noted Mr O had a poor oral intake and had been struggling with his tablets. It also noted the same day that he had eaten all of his lunch and taken his lunchtime medication.
146. On 4 January, the Trust noted Miss O had concerns about Mr O aspirating. On 9 January, the doctors said Mr O was at risk for occult aspiration (aspiration without any obvious signs or symptoms) and the nurses noted ‘SALT assessment?’. However, it appears no one took any action. On 18 January, the Trust again noted Mr O was at increased risk of aspiration and required a SALT assessment.
147. There is a mixed picture about whether Mr O was having difficulties with swallowing. Our geriatrician adviser said the Trust noted Mr O was experiencing fluctuating consciousness on 9 January, which appears to be why it was concerned he was at risk of occult aspiration.
148. In line with the GMC and NMC guidance, if the Trust had concerns about Mr O’s ability to swallow, it should have referred him to SALT for a full assessment. There is no evidence it ever made a referral.
149. If SALT had found concerns after assessing Mr O, then it could have recommended a consistency of food or fluids which were best suited to reduce his risk of aspiration.
150. Alternatively, if Mr O had failed the swallow assessment, then the next step would have been to consider nasogastric (NG) feeding. However, the Trust had already determined Mr O was not a suitable candidate. This was because of his confusion and because he was unlikely to have tolerated the NG tube.
151. What we can say is there appears to have been no impact from the Trust not referring Mr O to SALT. Our geriatrician adviser said there was no evidence Mr O suffered from aspiration pneumonia during the admission.
152. We have partly upheld this part of the complaint. This is because, while the Trust should have referred Mr O for a SALT assessment, we do not think the lack of assessment caused an impact.
153. Miss O is concerned the Trust switched Mr O from IV to oral antibiotics. She had concerns about whether Mr O could, or was, swallowing the medication.
154. Antimicrobials are medicines which are used to prevent and treat infections. The NICE antimicrobial guidance says IV antimicrobials should be used for a patient who needs empirical IV antimicrobials (antimicrobials directed against an anticipated or likely cause of infection) for a suspected infection. These should be used in line with local and national guidance.
155. When Mr O was first admitted, he was started on IV Tazocin which is a broad-spectrum antibiotic for sepsis. As Mr O’s clinical condition improved, the Trust changed this to oral antibiotics after 48 hours. Our geriatrician confirmed this was in line with the guidance.
156. On 8 December, Mr O’s condition deteriorated again. His temperature went up to 39˚C and his blood pressure was low. The Trust started IV hydrocortisone and IV Tazocin. Our geriatrician adviser said the source of the infection was unclear, so a broad-spectrum antibiotic, such as Tazocin, was appropriate.
157. On 11 December, blood cultures showed gram-positive cocci (a test using a chemical which shows whether bacteria are positive or negative – positive and negative bacteria will cause different types of infection and different types of antibiotics are effective against them). The broad-spectrum IV Tazocin was changed to IV flucloxacillin. Our geriatrician adviser said this would specifically cover the gram-positive organism.
158. The Trust prescribed IV flucloxacillin for seven days, before the Trust changed this to oral flucloxacillin. Our geriatrician adviser said it was appropriate to step the flucloxacillin down at this stage because Mr O appeared to be clinically improving, and it is appropriate to give oral antibiotics when the patient is clinically well.
159. We know Miss O has concerns Mr O was not taking the oral medication. There is conflicting information about this. On one hand, we have the nursing records which show Mr O took the medication. At times, nursing staff also checked Mr O’s mouth to make sure he had swallowed the medication.
160. On the other hand, we have Miss O’s account telling us the Trust did not ensure Mr O swallowed his medication, despite requests from the family about this. Miss O has provided a photograph showing crushed tablets left on a table, and a photograph of Mr O which appears to show a partially dissolved tablet in his mouth.
161. It appears from Miss O’s account that staff did not always watch Mr O as he was taking medication, and it is likely there were times when he did not swallow the medication. Miss O has explained that Mr O did not always understand that he needed to swallow his tablets.
162. It appears likely that, when considering Miss O’s account and evidence that on occasion Mr O did not swallow or was not given all of his medication.
163. There appears to be no impact of this. Our geriatrician adviser said Mr O’s clinical condition continued to improve while he was taking the oral medication. If he had missed a significant amount, it is likely this would not have occurred.
164. We think it is likely that on occasion, Mr O did not get the oral medication that was prescribed to him. However, we cannot see it had an impact on Mr O’s condition.
165. We think the Trust prescribed IV and oral medication in line with the relevant guidance and have found no failings relating to this.
166. Miss O is also concerned the Trust did not give Mr O additional hydrocortisone after he had been sick. She says they were aware of the importance of Mr O taking additional medication after being sick.
167. The GMC guidance says doctors must provide a good standard of practice and care. If they assess, diagnose, or treat patients, they must adequately assess the patient’s conditions, taking account of their history. Then promptly provide or arrange suitable advice, or treatment where necessary.
168. Mr O had a pituitary gland condition. He was dependent on steroid medication to receive this. Our geriatrician adviser said there are precautions that clinicians need to take if a steroid dependant patient becomes sick or injured.
169. The dose of steroids should be doubled where the patient has a fever, or sepsis requiring antibiotics otherwise an adrenal crisis could develop. Symptoms of an adrenal crisis caused by a lack of cortisol (a steroid hormone) include severe nausea, headache, dizziness, confusion, and low blood pressure.
170. The Trust prescribed IV hydrocortisone when Mr O was admitted. Our geriatrician said this was appropriate as Mr O was unwell.
171. We can also see the Trust doubled the dose of oral hydrocortisone when Mr O was unwell and reduced it to the usual dose when his condition seemed to be improving. On 28 November, the Trust doubled the dose for a week before it planned to go back to the normal dose.
172. On 30 November, the Trust noted Mr O had missed ‘a few’ doses of oral hydrocortisone. It noted Mr O could have IV hydrocortisone if the oral medication was not available. On 15 January, it appears the Trust gave him no hydrocortisone (either oral or IV).
173. We asked our geriatrician adviser what the impact was of missing these doses. Our adviser said it appeared there was no impact. There is no evidence to suggest Mr O was experiencing features of an adrenal crisis.
174. We have partly upheld this part of the complaint. We think the Trust failed to give hydrocortisone in line with the relevant guidance. It is clear from the records the Trust was aware of the importance of this medication. However, we cannot see this had an impact on Mr O.
175. Miss O is also concerned the Trust did not provide Mr O with nutritional supplements Actimel and Fortisip, as prescribed.
176. The NICE nutritional guidance says nutritional support (including supplements) should be considered in people who are malnourished or at risk of malnourishment. The guidance says the patient should be assessed for malnutrition or the risk of malnutrition. This should occur on admission and repeat every week.
177. The Trust assessed Mr O’s risk of malnutrition using the malnutrition universal screening tool (MUST). He was consistently found to score zero, meaning he was at no risk. Our nursing adviser said that given this risk, supplements would not be offered unless a poor nutritional intake was identified during the admission.
178. Mr O’s intake was variable. His weight remained stable, which indicated he was receiving sufficient nutrition. He received supplements on 14 and 28 December, 7 and 17 January. Our nursing adviser said these appeared to have been given based on clinical judgment.
179. We found the Trust acted in line with the relevant guidance. It assessed Mr O’s risk of malnutrition in line with the guidance. Based on this, there was no indication that Mr O required nutritional supplements. We have not upheld this part of the complaint.
Record keeping
180. Miss O complains about the Trust’s record keeping. She says the record keeping was poor and that the Trust failed to maintain accurate fluid balance charts and nutritional records.
181. Miss O has told us how she saw staff recording different meals to what she had fed Mr O. Miss O also says the family added to the records because staff did not always record Mr O’s intake.
182. Standards of general record keeping are set out in the NMC guidance. This says nurses should keep clear and accurate records which should be completed at the time, or as soon as possible after an event. The records should identify any risks or problems that have arisen, and the steps taken to deal with them, so that colleagues who use the records have all the information they need.
183. The NICE IV guidance covers the general principles for managing IV fluid therapy in hospital patients. It says fluid balance charts should be completed when a patient is given IV fluids.
184. We have no way of knowing now whether the nutrition records were completed in line with the guidance. On 28 November and 5 December, the records show Mr O only had one meal throughout the day.
185. It is possible these records accurately reflect Mr O’s nutritional intake on those days. It is also possible the Trust did not fully complete the nutritional records, and Mr O had eaten additional food which was not documented.
186. What we can say is that the records mostly appear to have been completed consistently. On the basis of this, we think it is more likely than not that the Trust completed the nutritional records in line with the NMC guidance.
187. The same cannot be said for the fluid balance charts. Our nursing adviser commented that until 10 December, these charts were ‘very poorly completed’. For example, on both 5 and 6 December, the charts show Mr O had one drink in the evening. No output is recorded for either day.
188. On 10 December, the fluid balance charts state for ‘strict input/output’. Despite this, staff did not fully complete the charts. Initially, there was more detail on the chart, but the Trust regularly failed to complete the total input/total output part of the chart. On 25 December, the chart is essentially blank.
189. This Trust did not complete nursing care plans, the dementia care plan, or the personal hygiene care plan. The catheter assessment is not fully completed and there are assessment charts with no patient information included. We have already detailed our concerns about the pressure care earlier in this report.
190. We have found the Trust’s record keeping fell below the standard set out in the NMC guidance and the NICE IV guidance. We have considered the impact of this on Mr O and his family.
191. These failings meant care Mr O received was not tailored to him. Without completing the care plan there is no way of knowing what Mr O’s preferences were or whether the Trust met these. This was important for Mr O, because of his dementia. Any lack of tailored care could have contributed to a sense of vulnerability or disorientation. Miss O has told us she feels her father was scared.
192. These failings also mean it is harder to address the questions Mr O’s family have about the care provided to him. The lack of records cast doubt on the level of care provided.
193. In the Trust’s response to the complaint, it acknowledged it had identified poor record keeping during its investigation. This was raised with individual members of staff, and more generally with the ward team.
194. We have considered whether these actions are sufficient. We do not think these actions address the individual injustice to Mr O or to his family. We have upheld this part of the complaint and have made recommendations to address this.
Complaint handling
195. Miss O complains about how the Trust handled her complaint. She says the Trust failed to keep to timescales, and she had to chase the Trust to get a response.
196. The NHS Complaints Regulations set out how and when to respond to complaints. They say the organisation should send a response as soon as reasonably practicable after completing the investigation. If this is not done within six months, the organisation should write to the person making the complaint to notify them.
197. Our Principles of Good Complaint Handling say organisations should be ‘customer focused’. Organisations should ensure the complaints procedure is simple and clear, involving as few steps as possible.
198. Complaints should be dealt with promptly, avoiding any unnecessary delay. Complaints should be acknowledged, and complainants should be told how long they can expect to wait to receive a reply. Complainants should be regularly informed about progress and the reasons for any delays.
199. Miss O sent a statement to the coroner as part of the inquest process in July 2018. In December 2018, the Trust acknowledged this statement. The Trust said it would undertake an investigation into the pressure damage, but it did not address the other issues Miss O had raised. It said it would write to Miss O to share the findings.
200. On 12 February 2019, Miss O wrote to the Trust. She said she had not received a response from the Trust, but she had become aware through the coroner that the Trust had completed a Root Cause Analysis (RCA). It appears this was completed in August 2018.
201. The Trust acknowledged this letter on 15 February. It told Miss O it would aim to complete an investigation within 45 working days, but that it would update her if this was not possible. The Trust responded on 8 May.
202. On 13 June, Miss O submitted a further complaint to the Trust. The Trust responded on 20 March 2020. The Trust apologised for the delay and said this was due to operational challenges which had resulted in a restructure of the Patient Advice and Liaison Service, and Complaints Team. It apologised for any additional concern Miss O had been caused.
203. Based on the information we have seen we think it is likely the Trust’s handling of the complaint was not in line with the NHS Complaints Regulations and fell below the standard we would expect in Our Principles of Good Complaint Handling.
204. We acknowledge there was some confusion about whether the statement Miss O provided to the coroner was a complaint under the NHS Complaint Regulations. Usually, the coroner’s process is separate to a complaint under the NHS Complaint Regulations.
205. Given this, we are not necessarily critical of the Trust for not initially considering the statement to the coroner as a formal complaint. We have considered the actions the Trust took after the coroner’s involvement below.
206. The Trust did respond to this in December 2018 however it seems odd that it decided to respond to only some of the issues raised. Either the Trust thought this was a complaint, in which case it should have dealt with all of the issues raised, or it was not. The process the Trust was applying was not clear, and this was not ‘customer focused’.
207. Having told Miss O it would respond, it then did not. We accept the Trust could still have responded inside the timescale set out in the NHS Complaints Regulations.
208. In response to Miss O’s complaint in February 2019, the Trust told her it would respond in 45 working days. This means the Trust should have responded by 23 April. It responded on 8 May. While this is outside of the timescale the Trust had set by about two weeks, we do not think this is so significant to be considered a failing.
209. Miss O submitted a further complaint in June 2019, which the Trust responded to in March 2020. This is an excessive delay. It is outside of the timescale set out in the NHS Complaints Regulations and cannot be considered as providing a timely response, without unnecessary delay. This was not in line with the NHS Complaints Regulations, or Our Principles of Good Complaint Handling.
210. We acknowledge that when the Trust did respond, it apologised for the delay and explained why this had occurred. It also apologised for the impact this caused and explained that it had taken steps to address this. We consider this apology is in line with Our Principles for Remedy, and as such, has addressed the failing in the time taken to respond.
211. In summary, we think there were failings in how long the Trust took to respond to the complaint, but that it has taken steps to remedy this. We do however think the Trust failed to be clear about its process, which was not in line with Our Principles of Good Complaint Handling. This caused Miss O frustration and confusion, which the Trust has not addressed.
212. We have partly upheld this part of the complaint and have made recommendations to address this.
213. Regulation 20 of the Health and Social Care Act sets out an organisation’s responsibilities under the Duty of Candour. It says, ‘a health service body must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users in carrying on a regulated activity’.
214. The Health and Social Care Act defines a notifiable safety incident as an unintended or unexpected incident, occurring during the providing of a Care Quality Commission (CQC) regulated activity, which has or might result in death, or severe or moderate harm to the person receiving care.
215. It says that where a notifiable safety incident occurs, the organisation must, as soon as reasonably practical, take action to notify the person (or next of kin). It must apologise, explain what investigations are appropriate, and provide the outcome of this as well as a written apology.
216. If the incident meets the notification threshold, staff should report it through the CQC notification system, or relevant NHS incident reporting system. The NMC Code of Conduct says nurses should identify any risks or problems that have arisen, and the steps taken to deal with them.
217. Staff first noted a grade two pressure sore on 8 January. Our nursing adviser said that at this point, in line with the guidance above, a Trust-wide patient safety incident should have been raised. We have seen no evidence that this occurred.
218. Our nursing adviser said a stage two pressure sore would not meet the criteria of ‘severe or moderate harm’ and would not therefore require use of the CQC notification system. A stage three pressure sore would meet the criteria.
219. We note the Trust’s response disputes the presence of a grade three pressure sore while Mr O was in their care. Poor documentation, including no wound evaluation, makes it difficult to know the timeline of Mr O’s sacral pressure area deterioration.
220. We have considered whether the presence of staphylococcus aureus bacteraemia, on 17 January, which the Trust noted was due to a pressure ulcer on the buttock, would have met the criteria of ‘severe or moderate harm’.
221. Our nursing adviser explained this was subjective. In the absence of the Trust recording a grade three pressure sore, if the Trust felt the infection would clear with antibiotics, it would not necessarily be reported.
222. However, when the pressure sore was confirmed as contributing to Mr O’s death (irrespective of the grading), it should have been reported under the Duty of Candour. The Trust failed to provide pressure area care to Mr O that was in line with national guidance. He subsequently sustained pressure damage, and this led to his death.
223. Our Principles of Good Administration say organisations should ‘act fairly and proportionately’. This means an organisation should always deal with people fairly and with respect. They should be prepared to listen to their customers and avoid being defensive when things go wrong.
224. Our Principles for Remedy say organisations ‘get it right’. This means an organisation should quickly acknowledge and put right poor service that have led to injustice.
225. When the Trust undertook a root cause analysis, it considered the tissue damage was unavoidable. The Trust changed this view only after an inquest, during which the coroner concluded Mr O’s tissue damage was grade three or four. In its response to the complaint, the Trust maintained Mr O was discharged from the ward with a moisture lesion which had developed to grade two pressure damage.
226. The Trust appears to have sought to deflect the failings in the care it provided by suggesting the hospice made a mistake in its grading of the pressure ulcer. It also suggested the hospice used a different tool, or that the training of the hospice staff was different. It has also said that in patients approaching the end of life, tissue damage can be accelerated.
227. Our nursing adviser commented that the Trust’s responses made excuses, rather than clearly outlining what happened, or saying that due to its poor records, it could not outline what had happened.
228. The Trust cannot say what pressure damage existed prior to Mr O’s transfer. It had failed to undertake an assessment prior to transfer. The hospice on the other hand had assessed Mr O’s skin on admission and it had found a grade three or four pressure sore.
229. Almost irrespective of what grade the pressure damage was to Mr O’s skin, it appears the Trust has failed to properly acknowledge that Mr O died as a result of its failings. Mr O died of sepsis, due to the staphylococcus aureus bacteraemia. This occurred as a result of the unassessed and untreated skin damage which occurred while Mr O was a patient at the Trust. Whether that damage was a grade two, three, or four, the impact of the complications that arose as a result were fatal for Mr O.
230. We think the Trust’s failings here are likely to have compounded the distress Miss O has naturally experienced following the death of her father. It is likely Mr O’s death occurred as a result of the Trust’s failings and the Trust has failed to recognise this, even after involvement from the coroner. This compounded and prolonged Miss O’s distress.
231. We do not think the Trust has acted ‘fairly or proportionately’ in this case, or ‘got it right’. We have upheld this part of the complaint. We are making recommendations to address the injustice Miss O has experienced.